Excellent agreement of Norwegian trauma registry data compared to corresponding data in electronic patient records.

BACKGROUND: The Norwegian Trauma Registry (NTR) is designed to monitor and improve the quality and outcome of trauma care delivered by Norwegian trauma hospitals. Patient care is evaluated through specific quality indicators, which are constructed of variables reported to the registry by certified registrars. Having high-quality data recorded in the registry is essential for the validity, trust and use of data. This study aims to perform a data quality check of a subset of core data elements in the registry by assessing agreement between data in the NTR and corresponding data in electronic patient records (EPRs). METHODS: We validated 49 of the 118 variables registered in the NTR by comparing those with the corresponding ones in electronic patient records for 180 patients with a trauma diagnosis admitted in 2019 at eight public hospitals. Agreement was quantified by calculating observed agreement, Cohen's Kappa and Gwet's first agreement coefficient (AC1) with 95% confidence intervals (CIs) for 27 nominal variables, quadratic weighted Cohen's Kappa and Gwet's second agreement coefficient (AC2) for five ordinal variables. For nine continuous, one date and seven time variables, we calculated intraclass correlation coefficient (ICC). RESULTS: Almost perfect agreement (AC1 /AC2/ ICC > 0.80) was observed for all examined variables. Nominal and ordinal variables showed Gwet's agreement coefficients ranging from 0.85 (95% CI: 0.79-0.91) to 1.00 (95% CI: 1.00-1.00). For continuous and time variables there were detected high values of intraclass correlation coefficients (ICC) between 0.88 (95% CI: 0.83-0.91) and 1.00 (CI 95%: 1.00-1.00). While missing values in both the NTR and EPRs were in general negligeable, we found a substantial amount of missing registrations for a continuous "Base excess" in the NTR. For some of the time variables missing values both in the NTR and EPRs were high. CONCLUSION: All tested variables in the Norwegian Trauma Registry displayed excellent agreement with the corresponding variables in electronic patient records. Variables in the registry that showed missing data need further examination.

Predicting the long-term impact of acquired severe injuries on functional health status: the role of optimism, emotional distress and pain.

STUDY DESIGN: Longitudinal. OBJECTIVE: To investigate the relative importance of personality traits, emotional distress and pain as predictors of functional health status in patients with spinal cord injury (SCI) or multiple traumas (MTs). SETTING: Sunnaas Rehabilitation Hospital, Norway. METHODS: Data were obtained from SCI and MT patients at admission (n=101) and at discharge (n=87) from rehabilitation, as well as 4 years post injury (n=75). The primary outcome measure was the sickness impact profile (SIP). Personality traits, that is, dispositional optimism and positive/negative affectivity, were measured using the Life Orientation Test-Revised and the Positive Affect and Negative Affect Schedule, respectively. RESULTS: Using hierarchical regression analysis, dispositional optimism and pain emerged as the most robust predictors of functional health status. Generally, these two variables accounted for a substantial part of the variance (that is, 20-40%) in the SIP scales. Significant correlations between pain and anxiety/depression were found in all phases of the study, and at follow-up depression level appeared as an independent predictor of functional health. CONCLUSION: The substantial predictive power, in terms of explained variance, of dispositional optimism, pain and depression/anxiety, indicates that these variables may be of practical-clinical importance in a rehabilitation setting. Specifically, patients characterized by low optimism, combined with presence of pain and depression/anxiety, may constitute a high-risk group for disability and reduced quality of life. On the other hand, high optimism should be regarded as a resilience characteristic, protecting the individual against long-term sequelae of severe physical injury.

The early effects of intramedullary reaming of the femur on bone mineral density; an experimental study in pigs.

BACKGROUND AND AIMS: Both fracture and fracture treatment affect bone mineral density (BMD). BMD after standard intramedullary reaming of the femoral cavity and after reaming with a reamer-irrigator-aspirator (RIA) system were studied with the hypothesis that the RIA technique would lead to lower BMD levels. MATERIAL AND METHODS: Dual-energy X-ray absorptiometry (DXA) was performed on the third day after operation with standard intramedullary nailing technique (n = 6) or RIA technique (n = 7) in intact femora of young Norwegian landrace pigs. RESULTS AND CONCLUSION: Significantly lower BMD were found in the mid-shaft and total femur after reaming with the RIA technique compared to the non-operated femur. Traditional reaming technique resulted in significantly higher BMD in the distal -femur. INTERPRETATION: The results of this study indicate that standard reaming increased BMD in the distal femur, suggesting compressive effects on trabecular bone. The RIA technique decreased BMD in the femoral diaphysis and total femur, suggesting removal of trabecular bone. A possible clinical impact of the findings remains to be investigated.

Long-term survival and risk factors for failure of the native hip joint after operatively treated displaced acetabular fractures.

AIMS: Our aim in this study was to describe the long-term survival of the native hip joint after open reduction and internal fixation of a displaced fracture of the acetabulum. We also present long-term clinical outcomes and risk factors associated with a poor outcome. PATIENTS AND METHODS: A total of 285 patients underwent surgery for a displaced acetabular fracture between 1993 and 2005. For the survival analysis 253 were included, there were 197 men and 56 women with a mean age of 42 years (12 to 78). The mean follow-up of 11 years (1 to 20) was identified from our pelvic fracture registry. There were 99 elementary and 154 associated fracture types. For the long-term clinical follow-up, 192 patients with complete data were included. Their mean age was 40 years (13 to 78) with a mean follow-up of 12 years (5 to 20). Injury to the femoral head and acetabular impaction were assessed with CT scans and patients with an ipsilateral fracture of the femoral head were excluded. RESULTS: A total of 36 patients underwent total hip arthroplasty (THA). The overall ten-year survival of the hip joint was 86% (95% confidence interval (CI) 81% to 90%) and the 20-year survival was 82% (95% CI 76% to 87%). Injury to the femoral head and acetabular impaction were the strongest predictors of failure, with the long-term survival rate falling towards 50% in these patients. The survival fell to 0% at three years when both these risk factors were present in patients aged > 60 years. CONCLUSION: The long-term survival of the native hip joint after acetabular fractures was good, but the presence of injury to the femoral head and acetabular impaction proved to be strong predictors of failure, especially in patients aged > 60 years. These patients may be better treated with a combination of open reduction and internal fixation and primary arthroplasty. Cite this article: Bone Joint J 2017;99-B:834-40.

Effects on peritoneal proteolysis and hemodynamics by high doses of methyl-prednisolone in experimental acute pancreatitis.

Acute pancreatitis was induced in 15 anesthetized pigs by injection of Na-taurocholate into the pancreatic duct. Seven animals were pretreated with methyl-prednisolone sodium succinate 30 mg/kg intravenously. Using chromogenic peptide substrate assays, values of trypsin (TRY), plasma prekallikrein (PKK), plasma kallikrein (KK) and functional plasma kallikrein inhibition capacity (KKI) were studied in the peritoneal exudate. Cardiac output (CO) and arterial pressure (AP) were regularly monitored before and during a six hour observation period. In acute untreated pancreatitis a 40% reduction of PKK levels was found paralleled by an increased KK activity and a reduction of KKI capacity. High TRY levels were found in several animals. The mortality rate was 63%. The pretreated animals all survived. CO and AP were significantly less reduced than in the untreated animals. Components of the plasma kallikrein-kinin system and TRY in the exudate remained mainly unchanged. Methyl-prednisolone given as pretreatment significantly improves hemodynamic parameters and increases the survival rate. Methyl-prednisolone suppresses generation of trypsin activity and activation of the plasma kallikrein-kinin system in the peritoneal exudate which may be of significant importance to the outcome.

[Fractures of the long bones, pelvis and spine. Why these injuries should be operated on as soon as possible]. / Brudd i de lange rørknokler, bekken og ryggskjelett. Hvorfor disse skadene må opereres snarest mulig.

The article addresses the pathophysiological aspects connected to multiple trauma leading to organ damage. Several studies have shown that early operative stabilization of fractures is a lifesaving treatment involving less pulmonary complications, a shorter stay in hospital and lower hospital costs than operation at a late stage. The author also discusses guidelines for diagnosis and primary treatment of the fractures, and the timing and tactics of the final operative treatment. When the patient has been stabilized and injuries with higher priority (thoracic, abdominal and head injuries) have been successfully treated, it is recommended to operate major fractures as soon as possible (within 24 hours). It is necessary to have a liberal attitude to early operative treatment of minor fractures and injuries to ligaments, since these injuries might otherwise immobilize the patient and reduce the potential for physical restitution. The treatment of multi-traumatized patients imposes demands for extensive skills and experience, not only on the part of surgeons and anaesthetists, but also among the whole trauma team, including nurses in the operating theatre, anaesthetist nurses and nurses in the intensive care unit. This means that care of multi-traumatized patients should be centralized to experienced trauma units.

[Amputation or reconstruction of a circulatory compromised severely injured extremity?]. / Amputasjon eller rekonstruksjon av en sirkulasjonstruet hardt skadet ekstremitet?

18 patients treated with primary or secondary amputations after severe lower limb open fractures were studied. All limbs had clinical signs of a compromised circulation at the primary evaluation. The various injuries are described and discussed with respect to the general guidelines for primary amputation. The Mangled Extremity Severity Score (MESS) and Nerve, Ischemia, Soft tissues, Skeletal, Shock, Age (NISSSA) scores were calculated. In view of the described injuries, primary amputation was indicated in ten patients according to the general recommendations, 11 patients according to NISSSA and 15 patients according to MESS. Delayed amputation leads t a significantly (p = 0.005) higher number of operative procedures than early amputation (9.2 vs. 2.9 treatments). The decision of whether to amputate or not should be based on sound clinical judgement, but injury scores such as MESS and NISSSA may be helpful.

No additional analgesic effect of intra-articular morphine or bupivacaine compared with placebo after elective knee arthroscopy.

BACKGROUND: Intra-articular pain prophylaxis is a controversial measure, adding costs although the benefits are still disputed. We wanted to evaluate the effects of intra-articular opioid or local anaesthesia or a combination of the two on postoperative analgesia and analgesic consumption after elective knee arthroscopy. METHODS: 107 patients with little or no preoperative pain and a minor surgical procedure were studied in a prospective, randomized double-blind design. The patients received midazolam 0.03 mg/kg intravenously before induction of general anaesthesia with fentanyl 1-2 micrograms/kg and propofol 2.0 mg/kg intravenously. Anaesthesia was maintained by a total intravenous technique with propofol infusion supplemented with alfentanil 10 micrograms/kg when needed. The patients breathed oxygen/ air through a laryngeal mask. By the end of the surgery they received 20 ml of test drug into the knee-joint: Group I (BM): 20 ml of bupivacaine 2.5 mg/ml with 3 mg of morphine; Group II (B): 20 ml of bupivacaine 2.5 mg/ml; Group III (M): 20 ml isotonic saline with 3 mg morphine; Group IV (P): 20 ml of isotonic saline (placebo). RESULTS: There were no significant differences between the groups in: time to first analgesic administered, analgesic consumption during the pre-or post-discharge period, nausea, somnolence, side-effects or postoperative pain perception during the first week. CONCLUSIONS: Intra-articular administration of morphine or bupivacaine is not indicated after elective knee-arthroscopy in patients with minor pre-operative pain and a small surgical trauma.

[Transiliacal screw fixation of the sacrum in unstable pelvic ring fractures]. / Transiliakal skruefiksasjon av sacrum ved ustabile bekkenringbrudd.

This article presents our experiences from fixation of the sacrum by transiliacal screw in 13 patients with unstable fractures of the pelvic ring. Early mobilization, with no secondary dislocation or postoperative complications, was achieved in all patients. Sagittal instability in unstable pelvic ring fractures must be acknowledged. The transiliac screw offers the possibility of early mobilization of patients with this fracture. The procedure is demanding and patients selected for this treatment should be referred to hospitals with experience in the treatment of pelvic fractures.

[Reconstructive surge of blunt renal trauma]. / Konserverende kirurgi ved stumpt nyretraume.

The most usual causes of blunt renal injuries are motor vehicle accidents, falls and participation in contact sports. Severe injuries are rare and a conservative approach in the treatment of such injuries is advocated by most authors. In this article we present a patient who suffered a major injury to the right kidney which was treated successfully by reconstructive surgery. We discuss the diagnosis of renal injuries, indications for surgery and surgical technique.

Activation of the plasma kallikrein-kinin system in respiratory distress syndrome.

Components of the plasma kallikrein-kinin and fibrinolytic systems together with antithrombin III were measured the first days postpartum in 13 premature babies with severe respiratory distress syndrome (RDS). Seven of the patients received a single dose of porcine surfactant (Curosurf) as rescue treatment. Nine premature babies without lung disease or any other complicating disease served as controls. There were no differences in prekallikrein values between surfactant treated and non-treated RDS babies during the first 4 d postpartum. The controls had, however, significantly higher prekallikrein values than the RDS babies already at the first day of age (mean +/- SD 32 +/- 8% in controls versus 22 +/- 6 and 21.5 +/- 5% in the treated and nontreated RDS groups, respectively). Plasma kallikrein activities did not differ between RDS and control patients. Plasma kallikrein inhibition values, which increased steadily in all groups, were lower in the RDS babies treated with surfactant than in controls at d 2 and 4. The degree of degradation of plasma high molecular weight kininogen was measured in RDS patients treated with surfactant and was significantly higher when compared with controls at d 1, demonstrating an increased proteolysis of kininogen to kinin early in RDS. There were no differences in plasminogen and plasmin values between RDS and control babies. This study shows that the plasma kallikrein-kinin system is activated in RDS. This system as well as the fibrinolytic system does not seem to be influenced by rescue instillation of a single dose of porcine surfactant into the lungs of premature babies with RDS.

Combined administration of dextran 70 and dalteparin does not increase perioperative blood loss compared to dextran 70 alone in major orthopedic surgery.

A prospective open-labeled clinical study was carried out to compare the safety of dextran 70 and low molecular weight heparin (dalteparin; DD group) versus dextran 70 alone (D group) in patients subjected to elective hip replacement surgery. Dalteparin, 5,000 IU/day and dextran 70, 500 ml during surgery and on the first postoperative day were administered to 214 patients. Dextran 70 alone was infused in 44 patients, 500 ml during surgery and on the 1st, 3rd and 5th postoperative day. Mean total blood loss during the operation and until the 2nd postoperative day was 1,708 ml in the DD group and 1,712 ml in the D group (p = 0.79). During the 1st postoperative week, no group differences were found in the relative number of patients that received packed red blood cells (p = 0.95), the amount of transfused packed red blood cells (p = 1.0) and changes in hemoglobin concentrations (p = 0.69). The present results suggest that dextran 70 and dalteparin can be combined in recommended doses without significantly increasing perioperative bleeding in patients undergoing hip replacement surgery. Bone traumatization and insufficient plugging of surgical traumatized bone surfaces with bone cement favor bleeding. Further well-designed studies are needed to evaluate the safety and efficacy of this regimen.

Extrinsic pathway inhibitor in postoperative/posttraumatic septicemia: increased levels in fatal cases.

The activity of the extrinsic pathway inhibitor (EPI), which is the factor-Xa-dependent inhibitor of the factor VIIa-tissue thromboplastin complex, was serially determined in 13 patients with postoperative/posttraumatic septicemia, and compared to the activity of antithrombin (AT), heparin cofactor II and protein C (PC). In the survivors (n = 8), initial low values for all the inhibitors normalized during recovery. In the demises (n = 5), a progressive increase in EPI activity was observed until death, whereas progressive decreases were observed for the other inhibitors. No correlation was found between the inhibitor values and the endotoxin concentration. We conclude that EPI activities are increased in the late course of fatal septicemia. Apparently, a large EPI-AT gap is a severe prognostic indicator in such patients.

Modulation of the proteolytic cascade systems by high dose corticosteroids.

The effects of high-dose corticosteroids (HDC) on activities within the proteolytic cascade systems were studied in vitro and in vivo using chromogenic peptide substrate assays. In in vitro experiments 20 mg methylprednisolone sodium succinate (Solu-Medrol) per ml plasma significantly inhibited activation of plasma prekallikrein, prothrombin and plasminogen and reduced functional plasma kallikrein inhibition, antithrombin and antiplasmin activities. The effects of HDC on activities within these proteolytic cascade systems were further evaluated in experimental acute pancreatitis in pigs. Acute pancreatitis was induced by injection of Na-taurocholate into the pancreatic duct. Seven test animals received methylprednisolone sodium succinate 30 mg per kg intravenously for 30 minutes before the induction of pancreatitis as pretreatment. Eight animals remained untreated. Trypsin (TRY), plasma prekallikrein (PKK), plasma kallikrein (KK) and functional plasma kallikrein inhibition capacity (KKI) were studied in the peritoneal exudate. Cardiac output (CO) and mean arterial pressure (MAP) were monitored regularly before and during a 6 hour observation period. During untreated pancreatitis a reduction of PKK levels of about 40% were found, paralleled by an increased KK activity and a reduction of KKI capacity. Several of the animals experienced high TRY activities. The mortality rate was 63% (5 out of 8 animals). In the pretreated groups, all animals survived the observation period. CO and MAP were significantly less reduced than the untreated group at 6 hours. HDC was also found to reduce significantly plasma kallikrein activities in the peritoneal exudate compared with untreated animals. No changes in TRY activities were found in pretreated animals. Furthermore, plasma prekallikrein and functional plasma kallikrein inhibition values in the exudate were elevated significantly in HDC treated animals compared with untreated animals.